There is little doubt that if screening rates had remained stable, many men who would have been diagnosed with prostate cancer would have had clinically indolent disease and been exposed to the considerable adverse effects of surgery or radiation with little or no survival benefit.

—David F. Penson, MD, MPH

A study finding that the incidence of prostate cancer has declined in recent years may at first seem like good news to physicians and patients, but, as widely reported by the media, the decline is not seen as an indication that prostate cancer has become less prevalent, but that screening for it has become less common. That study and another published in the same issue of TheJournal of the American Medical Associationreported that prostate-specific antigen (PSA) screening rates have declined since the U.S. Preventive Services Task Force (USPSTF) recommended omitting PSA screening from routine primary care for men.1,2

In an accompanying editorial3 and an interview with The ASCO Post, David F. Penson, MD, MPH, acknowledged the benefits associated with reduced PSA screening but expressed concerns about future increases of metastatic prostate cancer and mortality. Dr. Penson is Professor and Chair, Department of Urologic Surgery, and Director, Center for Surgical Quality and Outcomes Research, at Vanderbilt University Medical Center, Nashville.

Screening Decline Greater for Younger Men

Both studies found that although PSA testing declined for all age groups between 2010 and 2013, the decline was not as great for men over age 75, who already had been advised in 2008 not to have PSA screening. Dr. Penson said that by 2010, it was already “understood that prostate cancer screening in men in their late 70s and 80s was not as valuable as for men in their 50s and 60s.”

The recommendation against screening for younger men was a more abrupt change, but one that seems to be readily accepted by the men and their physicians. “Primary care physicians have a lot on their plate. They are not just worrying about prostate cancer screening. They are worrying about other cancer screening. They are worrying about cardiovascular health,” Dr. Penson commented. So when the USPSTF recommended not screening, that fit in nicely with the need of busy primary practices to save time. “But is it the right thing to do? I don’t think so,” Dr. Penson said.

Dr. Penson stated there are “some primary care physicians who don’t accept the USPSTF recommendation” and “patients who have made it very clear to their primary care physicians that they want the PSA test.” In most cases, if patients ask for a PSA test, they will get it, he added.

Troublesome for High-Risk Men

The prostate cancer–screening rates and incidence have dropped for both low-risk and high-risk men, and that could be particularly troublesome down the line for high-risk men. “One of the key points that people forget,” Dr. Penson reminded, is that prostate screening recommendations “apply to men with clinically normal risk for prostate cancer, in other words, the general population. But screening rates have dropped for everybody, even for high-risk men, and that could be a very bad thing, but we don’t know yet because we just don’t have the information,” he added.

“We don’t have good randomized clinical trials for men at higher risk,” Dr. Penson admitted. Applying findings about normal-risk individuals to a high-risk individual, such as an African American man with a family history of prostate cancer, “is the wrong thing to do, because the data are not based on someone like him,” he explained.

Uptick in Active Surveillance

“There are also benefits associated with reduced PSA screening,” Dr. Penson wrote in the editorial. “There is little doubt that if screening rates had remained stable, many men who would have been diagnosed with prostate cancer would have had clinically indolent disease and been exposed to the considerable adverse effects of surgery or radiation, such as sexual, urinary, or bowel problems, with little or no survival benefit. Acknowledging this, there is increasing evidence that active surveillance is becoming a preferred management strategy for men with low-risk disease.”

Patients are now more likely to understand that active surveillance is not the same as “watchful waiting” or doing nothing; rather it involves serial PSA measurements, with follow-up prostate biopsies, and intervention only if there is evidence of disease progression. This increased understanding “is one of the reasons why we are seeing an uptick in the use of active surveillance, because if you ask a guy would you rather have a prostate biopsy every 2 years or a radical prostatectomy tomorrow, most men would take option A,” Dr. Penson reasoned.

The Math Is Changing

“The math is changing in prostate cancer, and the concept of the harms of PSA screening is changing, because we are seeing a little more thoughtfulness on the part of both patients and providers, not just about when to get the PSA test, but also what to do once you get it, what to do once you have a biopsy,” Dr. Penson declared.

He conjectured that policy makers and USPSTF members may be “doing the math and in their minds they feel that the risks of treatment, of overtreatment, and the harms of being treated outweigh the benefit of avoiding a certain number of prostate cancer deaths. In my mind, I think everyone is entitled to make their own decisions about their health care. Some people are willing to accept the risk of overtreatment and harms of treatment for the potential benefit of avoiding a prostate cancer–related death.” Dr. Penson concluded: “Conversely, there are going to be men who say, my quality of life is very important to me, and I am not willing to risk it for a potential benefit in quantity of life. So I think it is an individual decision.” ■